Main Menu Home Page About Us Employee Benefit Solutions Products & Services Investor Info Latest News Our Green Policy Recruitment Contact Us Useful Tools Contact Us Site Map Help Legal Notices   © Personal Assurance Services Limited 2007 John Ormond House, 899 Silbury Boulevard, Central Milton Keynes, MK9 3XL Tel: 01908 605000 Fax: 01908 698040     Hospital Plan - Claim Form Request If you would like to make a claim, you can phone our claim line on 0845 120 1026 during normal office hours. Alternatively you can request a claim form by filling in the form below. To enable us to process your application, please fill in as much of the form as you can (fields in bold and marked with an * must be filled in). If you are not the Insured, please ensure that you also fill in the "Your Details" section in addition to the "Insured's Details" section. Insured's Details (please fill in as much of this section as possible)     Title:   *First Name:   *Surname:   *Date of Birth     Day:   (eg 19) Month:   (eg 4) Year:   (eg 1970) *Policy/Receipt Number   Address:   Post Code:   Phone Number:   Email Address:         Your Details (please ignore this section if you are the Insured)       Title:   *First Name:   *Surname:   Address:   Post Code:   Phone Number:   Email Address:         Claim Details (please fill in as much of this section as possible)       *In-Patient Claim:   Yes No *Out-Patient Claim:   Yes No *Maternity Related:   Yes No If Yes, when is the baby due: If No, please specify reason for admission / treatment:         If admitted to hospital     Date of admission         If not admitted overnight     Date of out-patient treatment:         Any additional details:           Please ensure the above details are as complete and accurate as possible, and then click on the Send Requestbutton.             data collection policy     Related Subjects: